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The Royal College of Surgeons (RCS) is the latest to join the growing chorus of medical colleges calling for change in hospital services with RCS President Professor Williams’s statement launching their new report: ‘2013 needs to be the year patients, politicians, clinicians and managers come together to support historic change in the NHS and create a lasting legacy for all of our population.’

This follows statements from the Royal College of Physicians – ‘we must radically review the organisation of hospital care’ – and the Academy of Medical Royal Colleges, which, in their call for a shift to seven-day consultant care, also argued that services will need to be reconfigured onto fewer sites. All the Colleges cite the need to adapt services to reflect advances in medicine and technology and the changing needs of patients, and therefore to drive up quality – arguments that have been made for decades.

So what is different about the RCS report? While arguing the clinical case for change, it also argues for meaningful engagement with the public on service change. Distinctively, the foreword to the report is written, not by the President of the College, but by the Lay Chair, Susan Woodward, who sets out the case for meaningful public and patient engagement. The tone of the RCS paper is a world away from the seminal paper Organisation of acute general hospital services produced by the Joint Consultants Committee (JCC) in 1999. In this the JCC pronounce ’It is important for the public to recognise that it is not possible for each locality to have its own small hospital to provide anything other than a restricted service.’

What flows from the RCS’s greater focus on the needs of patients seems to be an openness to try to find ‘win-win’ solutions or, at the very least, a means of mitigating the potential downsides for patients that may come from service change. For example, they propose the development of surgical clinical networks, supported by telemedicine and other technological support, with surgeons working across multiple sites. They also propose strengthened ambulance services with additional training for paramedics, allowing a model of care in rural areas in which patients would be triaged so that only those needing specialist care would have to travel long distances. The RCS also addresses some of patients’ key concerns by arguing that transport issues need to be central to any planning process; that consultation should be genuine and not tick box; and that any service change should be monitored and evaluated.

This should be music to the ears of the Independent Reconfiguration Panel (IPR), who are charged with reviewing contested proposals for NHS service change, as this closely aligns to their ‘critical list’ of key lessons learnt. This includes:

the clinical case not being convincingly described or promoted

clinical integration across sites and a broader vision of integration into the whole community has been weak

proposals that emphasise what cannot be done and underplay the benefits of change

health agencies caught on the back foot about the three issues most likely to excite local opinion – money, transport and emergency care.

The RCS’s approach is very welcome, and let’s hope that it translates into a genuinely different dialogue at a local level – a dialogue based on evidence. In my view, the problem is not just how we engage with the public but about the evidence on which the dialogue is based – the first issue on the IRP's critical list. For example there is little evidence of volume and outcome benefits for the majority of general medical care and such benefits that do exist have much lower volume thresholds than those in specialist surgery. Yet consultation documents often imply that the benefits are similar. It is also rare for the public to be shown evidence of current deficits in quality. The RCS suggests that greater use should be made of national clinical audit data. In our report on Improving health and health care in London, we found that the data showing variation in the quality of stroke services was very powerful in generating public support for change. If we are to have the ‘historic change’ sought by Professor Williams it needs to be change supported by robust evidence.

Comments

susanne stevens

Position

n/a,

Organisation

n/a

Comment date

18 January 2013

There seems to be a real misunderstanding about how much 'the public' is informed about how any part of the NHS works/is funded.......'consultation'?? How many have given up in disgust about the tokenistic way they have been used?

Leslie Hamilton

Position

Consultant Cardiac Surgeon,

Comment date

18 January 2013

If a service review is carried out thoroughly with input from a wide range of sources at the stage of developing proposals for change, then most issues which are raised during public consultation will have been considered already - some might interpret this as "not listening".

In any national reconfiguration of a specialised service into larger centres, some local areas will experience change and this will inevitably stimulate opposition. It will always be difficult to convince people that the overall service will be better.

If proposals for change are based on the unsustainability of the current service (because of expertise being spread too thinly) then the "robust evidence" will only be produced by auditing the new service.

celia davies

Position

professor emerita,

Organisation

The Open University

Comment date

25 January 2013

So it really is coming to pass, is it? ‘Grown up patients and grown down doctors’ I once called it. All credit to you Candace for underlining what an important new move is marked by this RCS report. But let’s not forget the challenges – of creating an atmosphere of respect, of enabling informed dialogue and getting over the fear (yes really) that clinicians and managers can sometimes feel about working with patients and the public in new ways. I would say this, of course – but ‘Better Health in Harder Times’ (Policy Press Nov 2012) is full of inspiring examples written not by us editors, but by professionals, patients and the public of the service transformation they have achieved – as well as containing honest accounts of the personal challenge and personal growth from working together. I look forward to seeing how the Fund is going to support this important agenda in 2013.